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All Journal Indonesian of Health Information Management Journal (INOHIM) Jurnal Kesehatan Tambusai PELS (Procedia of Engineering and Life Science) Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK)
Cindy Rozza Bella
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Computer Science & IT Control & Systems Engineering Dentistry Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

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Journal : PELS (Procedia of Engineering and Life Science)

 1 
Analysis Of Pending Claims For Inpatients Social Security Organizing Body (Bpjs) Health Hospital Mitra Siaga Tegal: Analisis Pending Klaim Pasien Rawat Inap Badan Penyelenggara Jaminan Sosial (Bpjs) Kesehatan Rumah Sakit Mitra Siaga Tegal Indira, Zahrasita Nur; Yustafia, Atiqah Filda; Wijayanti, Wahyu Nur; Bella, Cindy Rozza; Mulyani, Agustina Dwi; Wibowo, Dimas Ari
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2237

Abstract

The Hospital understands and realizes the importance of the claim process as a reimbursement for insurance patients who have been treated. pending claims, namely the return of claims where there is no agreement between BpJS Health and FKRTL regarding coding and medical rules (dispute claims), but settlements are carried out in accordance with statutory provisions. Mitra Siaga Tegal Hospital in September 2022 obtained data that there were 94 pending BPJS claim files for inpatients out of 1427 files that had been submitted for claims to BPJS. This is due to coding errors, incorrect data entry, incomplete supporting examinations such as the absence of therapy and laboratory results. The method used in this research is qualitative with in-depth interviews with the Assistant Manager of Insurance Control and the officer in charge of Inpatient Claims at Mitra Siaga Tegal Hospital. The purpose of this study was to find out the causes of pending claims for hospitalization in September 2022 at Tegal Mitra Siaga Hospital. The results of the study show that pending cases of inpatient BPJS claims at Mitra Siaga Hospital in Tegal can occur due to several factors, which consist of administrative, medical, and coder aspects. The most common factor causing pending hospitalization claims was the coder aspect in 76 cases
Overview of the Causes of BPJS Health Pending Claims Due to Inaccuracy of Diagnosis Codes in Sebelas Maret University (UNS) Hospital Bella, Cindy Rozza; Pratama, Aldi; Abidin , Arif Zaenal
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i1.1933

Abstract

In submitting a BPJS Health claim, not all submitted documents can be claimed. Claim status is declared ineligible or pending. A pending claim occurs if the claim file submitted by the hospital is incomplete or does not comply with the requirements set by BPJS Health. Delayed claims can disrupt hospital cash flow and cause losses for the hospital and BPJS Health participants. This research aims to describe the causes of pending claims at UNS Hospital. This research is a quantitative descriptive study with a population of 182 inpatients pending claim documents at UNS Hospital for the period August-October 2023. The sample for this research is 78 pending claim documents based on diagnosis code verification. The sampling technique is total sampling. Based on the data obtained, the number of documents with coding confirmation is 78 pending claim documents s or 11.3% of the total pending claims in the period August – October 2023. This data shows that the majority of pending claim documents are due to inaccurate diagnosis. The factor causing pending claims from BPJS Health inpatients at UNS Hospital occurs due to differences in perception between hospital staff and BPJS Health and is not purely due to coder error, but due to a lack of supporting data as a diagnosis enforcer which affects the accuracy of the code.
Co-Authors Abidin , Arif Zaenal Budiyanti, Shifa Amanda Isnaeni, Rizka Mulyani, Agustina Dwi Pratama, Aldi Ummah, Shofiatul Wibowo, Dimas Ari Wijayanti, Wahyu Nur Yustafia, Atiqah Filda Zaenal Abidin, Arif Zahrasita Nur Indira